ABSTRACT
This research was conducted in two communities; Dandu and Wuro Chekke, Yola
south, Adamawa state. The aim of the study was to investigate the availability of
sanitation infrastructures and to find out the relationship between sanitation and
health among children in the two rural areas of the state. This was done by
conducting interviews and making observation of 50 respondents who were mainly
mothers and their environment. The socio-economic status and sanitation practices of
the respondents, water supply source, and availability of health care centers in the
areas and some of environmental conditions of their communities were included in
the interviews and the observation process. The factors were considered in other to
find out if there was any relationship between the factors mentioned above and the
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occurrence of malaria, typhoid and intestinal worm infestation in the children under
the age of five.
Results from the study were analyzed using charts mostly and the results showed that
in the two communities, there was hardly any link between the factors that were used
to measure sanitation or the standard of living and the diseases in the children. There
the hypothesis of this study which is that “There is a relationship between the health
of a child and the level of sanitation, water quality and low income in rural areas”
was not proven due to time limitations and also lack of records showing disease
occurrences in children less than five years in the communities.
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Table of Contents
DEDICATION …………………………………………………………………………………………………………. iv
ACKNOWLEDGMENT …………………………………………………………………………………………….. v
ABSTRACT …………………………………………………………………………………………………………….. vi
INTRODUCTION ……………………………………………………………………………………………………. 1
Environmental Health in Nigeria …………………………………………………………………………….. 8
Controversy on the Relationships between Diarrhea and Growth ………………………………… 8
Research questions ………………………………………………………………………………………………. 11
Objectives of the study …………………………………………………………………………………………. 11
Aim/ expected research outcome …………………………………………………………………………… 12
RESEARCH METHODOLOGY ………………………………………………………………………………. 13
Introduction ………………………………………………………………………………………………………… 13
Study area…………………………………………………………………………………………………………… 13
Research Method ………………………………………………………………………………………………… 13
Target Population ………………………………………………………………………………………………… 14
Method of Data Analysis ……………………………………………………………………………………… 14
Data collection ……………………………………………………………………………………………………. 14
HYPOTHESIS ……………………………………………………………………………………………………. 14
RESULTS AND ANALYSIS …………………………………………………………………………………… 15
Socio- economic/ familial structure of respondents in both communities ……………………. 15
Sanitation Facilities/ Hygiene Variables …………………………………………………………………. 18
DISCUSSION ………………………………………………………………………………………………………… 22
Limitations …………………………………………………………………………………………………………. 23
CONCLUSION ………………………………………………………………………………………………………. 24
RECOMMENDATIONS …………………………………………………………………………………………. 25
REFERENCES ………………………………………………………………………………………………………. 26
INTERVIEW GUIDE ……………………………………………………………………………………………… 27
1
INTRODUCTION
Environment, sanitation and health are inextricably interlinked. An environment with
poor amenities such as polluted air, poor sanitation, unkempt drinking water and
poor housing, has been seen to have a negative effect on the health status of
individuals and wellbeing of people. Such places have added to communicable
disease and also in the prolonging of epidemiological transition. Physical
environmental factors and socio-cultural issues which are cumulative also lead to
disease of greater burden. The environment in the medical sense includes what
affects an organism with regards to influence and condition and also the
surroundings. For the purpose of this paper, environment by the International
Epidemiological Association can be defined as “All that which is external to the
human host. This can be divided into physical, biological, social, cultural, etc., any or
all of which can influence health status of populations.” From this definition,
anything that is not genetic would be included in the environment. However, this can
be argued because considering genes for instance whether in the short or long term,
they are influenced by the environment.
Looking the globe as a whole, the health burden is on the increase; even the so-called
developed world deal with pollutants that emerge every now and then which pose a
considerable threat to human health. Urbanization is on an alarming rate in the
developing countries. In 2001, according to the United Nations, Nigeria had a
population of 167 million which affected the housing demand in the urban area. As
such, haphazard development for new migrants or less privileged ones has resulted in
slum development. In contrast to this background study, there is the crucial need for
action to aid with the reduction of environmental health burden within the rural areas
2
of the country. The rural or slum development is commonly seen in developing
countries. This has built up problems that can be witnessed in different urban centers
where infrastructure provided lag behind in city expansion and population growth.
The group which is most vulnerable to environmental burdens is the occupants of the
rural area.
Similarly, in developing countries, gastroenteritis can be seen to represent morbidity
in children. Within these developing countries, the annual diarrhea rate is estimated
to 3.2 events per child (). Zones that are considered to be endemic, colonization of
these parasites are the norm. This can be as a result of malnutrition which is also a
cause of immune deficiency. Parasitic diarrhea is frequent and acute among children
that are not well fed or malnourished, children who are well-fed on the other hand
remain healthy carriers. More so, diarrhea can be seen as a possible cause and
concern of malnutrition. Diarrhea also stunts children’s growth, malnutrition increase
the diarrhoeic frequency which creates a vicious cycle.
The negative effect of diarrhea infection on the state of nutrition can be due to the
following reasons: by increasing catabolism and the stocking of micro nutrients
needed for tissue growth and formation intestinal absorption and appetite reduction.
The case of retarded growth in a quarter to a third per case is due to intestinal
infection as explained by mathematical models.
Dating back to the 1980’s, even the mildest form has been seen or known for
weakening immune defenses. Micro-nutrients play a role which allows adequate
immune responses to attacks which is now being accepted and the effects which are
pathological of the most common deficiency types are also recognized.
3
With the aforementioned, this paragraph delves into malaria owing to the fact that it
is part of the case study also side malaria, diarrhea and intestinal worms.
Malaria and intestinal helminth parasites co-exist in the tropic as a result of climatic
conditions that are prevailing and also due to poor sanitary practices. The effects of
these parasites are cognitive in development, school attendance of children and also
educational performance. The full documentation of these parasites has not been
fully recorded in Nigeria due to the fact that community-based studies are limited.
The general plasmodium prevalence parasites which are asexual, intestinal helminth
infections and helminth malaria infections were about 52.3% and 57.1% respectively
(WHO, 2012). It should also be known that in children Ascaris lumbricoides was the
only intestinal species identifies amongst children.
Malaria and helminth infections are distributed widely in both tropical and
subtropical areas which of course are both of public health concern. Children under
the age of five die from malaria every 30 seconds (Ekundayo, 2011). In Nigeria,
intestinal helminth infections with Trichuris trichuiris, Ascaris lumbricoides and
hook worm, have remained dominant. The latest report shows about 102 countries
still endemic for malaria with about 219, 000, 000 cases and 660, 000 deaths
(Ekundayo, 2011). Nigeria and the democratic republic of Congo account for 40%
total of the estimated deaths related to malaria and also 40% of the malaria cases
globally.
These diseases are common amongst children because they are more susceptible to
the two infections owing to the incomplete development and their greater
immunological vulnerability, lower standard hygiene and morbidity (Montresor and
Crampton, 2002). Helminth that is soil transmitted amount for about 10% of any
4
population understudied. The most vulnerable are school children. 28.6% to 75.6%
of ascariasis is prevalent amongst school children and factors such as poor hygiene,
poor water supply, and poverty, limited access to preventive measures, health care
and lack of protective clothing.
Some few decades ago, there have been similar infections with regards to worm and
malaria. The relations between these two studies of infection have been reported to
be proactively different or to aggravate prevalence of acute malaria. Despite
environmental conditions and socio-economic factors that affect the distribution of
malaria and helminthes, especially with regards to children and the rural
communities, a brief explanation of what studies has revealed can be viewed within
the next paragraph.
Findings from these studies have demonstrated a serious persistence of intestinal
helminth infections, asymptomatic malaria infections and anemia commonly found
amongst children in rural areas. An overall prevalence of falciparum malaria
accounts for about 52.3% which is hyper-endemic for malaria. However, the high
prevalence of asymptomatic malaria which is more rampant during the dry season is
a cry for attention because this could be one of the reasons why malaria is hyperendemic
within the study area. Children under the age of five have been seen to have
an immunity which develops progressively form childhood to adolescence.
Socio-economic status basically affects three areas of health which are healthcare in
general, health behavior and environmental exposure. Considering the United States,
it has been found that health worsens especially from families who stay in low
income areas with little or no education. On the other hand with an improvement in
5
socio-economic status, so did the overall health outcome. This can also be said about
African children as well as Hispanic with same indicators of health improving as
income and education levels change.
There was an overall prevalence which was observed for intestinal helmith infections
in which children were used for the understudy, this showed a decline in prevalence
which when compared to the 2005 report. The reason for the decrease in helminth
could be as a result of campaign or Ivermectin, however the case maybe.
Another study showed that children without intestinal helminth infections were about
two times likely to have a positive test for malaria parasite as compared to children
already with the infection. This study has been in contraction and arguable according
to findings by Ojurongbe in Osun state, this study and similar studies in Thailand
shows a rather positive and statistical relationship between malarial infection and
geohelminth respectively. The reasons for such cannot be explained and requires a
deeper research into why such occurs. To support such findings, a research was done
in Ghana there was a relation between helminth and increased levels of Interleukin
which is known to inhibit the protective immune responses against malaria parasites
which can also be seen in exacerbating parasitemia common to plasmodium
infection. This result from Ghana suggests that the infections cause by helminth may
have an alteration towards the immune response of antimalarial through the
suppression of proinflammatory activity.
The above study has showed that malaria and co-infection are mostly common to
children within the rural areas. Most importantly, for parasitic infections, age is an
independent factor for both parasitic infections. The findings serve as a guide to
6
future research on prevention and control of children that reside in rural areas of
Nigeria. This also provides a ground as to how to tackle the issues of malaria within
the rural communities.
According to Corvalán in 2006, the estimated global disease burden and death
percentage are 24 and 23 respectively which in most cases can be attributed to
environmental factors, which in a sense can be averted with environmental
modification which include provision of safe water, adequate hygiene and standard
sanitation. International bodies such as The United Nations Children’s Emergency
Fund (UNICEF), the World Health Organization but to mention a few have proved to
be concerned and in some cases lend a helping hand to curb environmental issues in
various parts of the globe. The risk posed by environmental factors contributes at
least 80% of major diseases in the world today (). Within the developing countries,
the rate of environmental disease is a burden, if compared to the developed countries
the difference is fifteen times higher (Smith et al 1999). “Available global evidence
suggests that (a) lack of access to clean water and sanitation and (b) indoor air
pollution are the two principal risk factors of illness and death, mainly affecting
children and women in poor families.”
The result accompanied by such health risks on both sexes due to the environment, is
cumbersome if measured in millions. As a result the need for a healthy environment
cannot be overemphasized especially within countries that are poor. The need for
better access to safe and secure drinking water, better the air quality, provision of
quality sanitation that is, both indoors and outdoors. In 2005 UNICEF and WHO
stated that “1.1 billion people lack access to safe drinking water; 2.6 billion are
without proper sanitation.” Poor sanitation and contaminated water on a yearly
7
basis contribute towards the 5.4 million case of diarrhea across the globe (), in which
there are about 1.6 million deaths (Haller 2004) in which majority are children under
the age of five (as stated in the introduction). Intestinal worms grow well or survive
better in sanitary conditions that are poor which is common to communities which
are poor. These poor communities are more prevalent in the developing world. The
prevalence of these communities has left nothing less than two billion people
infected and in most cases it depends on the severity of such infections, in some
cases it may lead to retarded growth, anemia and also malnutrition as the case maybe
(WHO 2006). In 2006 UNICEF’s report it can be seen that apart from diarrhea, “six
million people are blind from trachoma” which is disease by poor hygiene practices
and lack of water.
Within the developing countries, the population affected the most are those living in
extreme conditions of poverty, be it in the urban or slum areas or rural as the case
maybe. The pollution cause by indoors is responsible for over 1.5 million respiratory
infection every year and also about 2.7 percent of the disease burden globally (WHO
2007). Looking at the world at large, half of the population use biomass and coal
(solid fuel) for cooking and heating space which is attributable to indoor air pollution
(WHO 2007). The poor health burden is mostly found in children under the age of
five, women, the elderly and the disabled. In as much as, most deaths are attributed
to indoor use of solid fuel and kids under the age of five, the countries affected the
most include China, Ethiopia, Tanzania, Nigeria, Angola, Pakistan, India and a host
of others (). The outdoor pollution is mostly experience by men as a result of bad air.
However, the burden of the pollution is rested upon the children under the age of five
(WHO 2008); this is because they are vulnerable to risks from the environment
8
(UNICEF 2006). Malaria is a disease caused by a parasite belonging to the
plasmodium genus. This so called parasite can be transmitted by a bite of a female
known as Anopheles mosquito already infected.
Environmental Health in Nigeria
Analysis from the issues facing health related problems in Nigeria gives a peculiar
scene to double countries. A scene which is jeopardizing resulting from traditional
environmental issues related with poverty, poor development as well as the location
problem of industries and urbanization which has led to degradation of the
environment and natural resources exploitation (Ahmed and Murtaza, 1995). Basic
problems associated with the environment include unsafe water supply, poor food
sanitation, lack of sanitation and poor vector control but to mention a few. In a
survey conducted by the Nigerian Demographic and Health Survey in 2003, shows
that 34.1%, 28.7% and 61.1% of rural homes have no toilet facilities, use toilets and
use pit latrines respectively (Blum and Feachem, 1983). Within the same survey it
showed that most rural indigenes are unable to access clean drinking water which
leads to more health problems. Most of the water gotten is either from rivers,
streams, open wells. The secondary problem includes noise pollution, industrial
pollution, ozone depletion and a host of others.
Controversy on the Relationships between Diarrhea and Growth
There has been research as to the relation between diarrhea and growth. Few
researchers came together to try and explain why. From their work they stated only
malnutrition can be held responsible for the stunting of growth and the infection.
9
This survey was carried out in the Gambia within the late 1970’s (Briend, 1989)
which saw the close relationship that exists between diarrhea and growth. The results
were somewhat suggestive that the diarrheic episodes and curves gotten could be
brought together except during raining season. From the research there was a
noticeable decrease in the severity number, however, the children’s growth remain
the same. As a result, there was a conclusion that the improvement in their weight
curve had nothing to do with their diarrheic cases.
Although there’s the possibility that growth could be the consequence of daily food
supplement (Briend, 1990), this does not relate to malnutrition. In Bangladesh a
survey was carried out on little children from 6 to 35 months and this showed a long
time effect of diarrhea in relation to growth were not significant. Even if the
deficiencies of diarrhea were acquired they disappeared after a few weeks. Looking
closing at other analysis from various papers will show a challenging stand played on
the part by diarrhea and malnutrition. However these data are not quite clear if
diarrhea is a major cause of malnutrition. In Indonesia a study showed that there is
no link between diarrhea and growth, however, there is a relationship between
respiratory infections and growth.
Relating back to the impact diarrhea has on water, the water supply and sanitation
needs to be improved and also have a strong effect with regards to the mortality and
morbidity of various infections. The access to water if improved will reduce the
diarrheic infection by 22 per cent, human waste by 16 per cent. However, this might
not be too true owing to the fact that if water is improved it will account for 37 per
cent in reduction rather than 41 per cent as presumed by laboratories ().
10
Analyses from the effect and studies that relateto diarrhea cannot be in totality be
dealt with within the limits of this paper but however the role hygiene plays an
important role which is vital due to the reason that most diarrheas that are endemic in
nature can be passed between people due to lack of hygiene. As simple as a hand
wash is in high risk diarrhea populated areas have been widely understudied and
even though has not gone beyond methodological criticism, there is a general
preference that it helps with the reduction in contracting diarrhea infection.
Diarrhea is also one of many symptoms responsible for intestinal infections. In the
rural areas especially, no matter the individual’s health status, it is very easy to be
faced with intestinal parasitic colonization. There are different diarrhea parasites but
the most common are Cryptosporidium, histolytica and Giadia lamblia. No matter
the test or the clinical impact, it will largely depend on the immune system of the
individual which is usually the host. If the immune defenses are low diarrhea is more
frequent. As stated earlier malnutrition is still a major cause and children that are
well fed are healthy parasite carriers. The best way for diarrhea to be treated is for
malnutrition to be addressed alongside children’s immunodeficiency.
Intestinal worms can be seen to have a corresponding relationship with diarrhea due
to the fact that infection occur when an individual has taken water that is
contaminated, air pollution, and a few other reasons as rightly stated earlier in the
paper. In Gambia, survey according to Lunn in 2000 shows that about 43 per cent of
children within the age of 15 months show signs of reduced Intestinal absorption
known as malabsoption. Few other studies have also been conducted as well and
shown that food supplements composed mainly of naturally fillings from plants
11
could help reduce the intake of these worms through food which can be contaminated
by pathogens.
The immune system during this nutrition and infection shows knowledge of existing
relationships which exist between the immune system, malnutrition and infection. In
another research in the late 1990’s, malnutrition even in its moderate form can be
seen to weaken the immune system. This in turn leaves the body exposed to all these
bacteria especially in undernourished children or few adults who reside in developing
countries mostly within the rural regions.
Research questions
I. Is there adequate hygienic water supply in the area?
II. Are there any adequate health care facilities in the areas?
III. How is waste handled or disposed in homes and generally in the community?
IV. What is sanitation or hygiene levels using different variables like hand
hygiene after defecation, presence of cockroaches and rats, drinking water
care?
V. What is the effect of standard of living and educational background on their
sanitation or hygiene practices?
Objectives of the study
For the purpose of this work the specific objectives of the study shall be;
I. To assess water supply in the communities
II. To assess available health care facilities in the areas
III. To find out how waste is handled or disposed in homes and generally
in the community.
12
IV. To assess sanitation or hygiene levels using different variables.
V. To find out if their standard of living and educational background has
any effects on their sanitation or hygiene practices.
Aim/ expected research outcome
The aim of this study is to investigate the availability of sanitation infrastructures and
to find out the relationship between sanitation and health among children in two rural
areas in Yola, Adamawa state.
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